Telehealth And State Lines: More Thoughts

I have written previously about laws regarding state lines, licensure, and telehealth services. The way laws are currently written, a therapist must be licensed at the client’s physical location at the time of service in order to provide care. Some states have enacted exceptions to this law; for example, some providers can continue seeing an existing client for continuity of care even if the therapist does not get licensed in an additional state. However, for the most part, the expectation continues to be that providers obtain licensure in any jurisdiction where their clients will be.

In my deep dives into these laws as a telehealth expert (that’s what PESI calls me based on my experience and knowledge, isn’t that cool?), there are some rationales behind this rule, but honestly none of them seem to hold up:

1. What If The Client Experiences A Crisis? Providers are most well-versed in the crisis resources in their geographic area, so if a client is in a different state, how will I know where to refer them to? Well, there is this awesome new thing called a search engine that allows anyone to find resources in any geographic area in seconds! Since I am currently licensed in six states, I keep a spreadsheet of local resources in all jurisdictions. I would simply have to make sure that I maintained these resources for any other locations where I have clients – which would not be difficult. We all managed these crises when states offered reciprocity in early COVID days.
2. What If A Client Needs To Report An Unethical Provider? If I am inappropriate with a client, they have the right to report me to the licensing board that oversees the jurisdiction responsible for me. If I see clients outside of where I am licensed, clients still have the right to report me to my licensing board. But thanks to the internet, anyone anywhere in the world can get the email and phone contact information for all my boards, again within seconds. So the oversight is still there.
3. What If The Client Needs To Be Seen In Person? I will acknowledge that, if a client might need to be seen in person, they might have trouble with a telehealth provider who is not in their geographic area. However, this already exists within jurisdictions. You can drive more than five hours to the West of my office without leaving South Dakota, so plenty of clients I’m licensed to treat already not in a position to come in person. As with crisis resources, I keep information about in-person options so that I can make appropriate referrals as needed.

Some clients might even prefer to choose a therapist who is not in their immediate geographic area for a variety of reasons:

1. Privacy. I have a colleague who specializes in mental health for pastors. Before telehealth became an option, their clients expressed concern about parishioners seeing them in a therapist’s waiting room or encountering their therapist in the context of their work. If you have the option to choose a therapist who is located more than 1,000 miles away, you can have added privacy in your treatment.
2. Dual Relationships. As a therapist who has done my own therapy, I can tell you it is impossible to find a provider licensed in my location with whom I do not have a pre-existing professional relationship. Changing jurisdiction laws opens up my options.
3. Specialization. When I first got TF-CBT certified, I was the only provider in South Dakota with that training. What if someone wants or needs that treatment protocol, but I don’t have openings? You should have the right to choose a provider based on who meets your needs even if they don’t happen to live in your state.
4. Continuity Of Care. As a provider who works with kids, let me present you with a scenario. (The same scenario can of course apply to adults as well.) Your family is moving to another state. You will live in a different house, have a different bedroom, go to a different school, and you do not know when you’ll see any of your friends again. On top of all that, your therapist says they can’t keep seeing you out of state even though you have video sessions, and you could join a Zoom meeting from anywhere. How is that fair?

In conclusion – let people choose their providers! PsyPact and other compacts are working towards making reciprocity a reality, but they have not fully solved the problem (I’ll speak to this in another post). We need national standards and protections.